陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 9熏晕燥援 12熏 Dec.18, 圆园16 www.ijo.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 窑ClinicalResearch窑 Etiology,diagnosis,managementandoutcomesof epiphorareferralstoanoculoplasticpractice

1DepartmentofOphthalmology,ZhongshanHospitalof INTRODUCTION FudanUniversity,Shanghai200032,China piphoraortearingisthepresenceofawateringeye, 2CaseyEyeInstitute,OregonHealthandScienceUniversity, E which isacommoncomplaintforreferralsto Portland,Oregon97239,USA oculoplasticsclinicsforevaluation.Theetiologyoftearing Correspondenceto: JohnD.Ng.CaseyEyeInstitute, canbedividedintotwocategories:reflextearingand OregonHealthandScienceUniversity,3375SWTerwilliger reducedtearoutflow[1].Reflextearingisusuallysecondaryto Blvd, Portland,Oregon97239,USA. [email protected]; dryeye,inflammation,allergyorotherocularsurface Xiao-PingMa.DepartmentofOphthalmology,Zhongshan disorders,whereasprimaryhypersecretionofthelacrimal HospitalofFudanUniversity,No.180FengLinRoad,Xuhui glandsisrare.Reducedtearoutflowisduetoeyelid District,Shanghai200032,[email protected] malposition,tearpumpdysfunctioncausedbyeyelidlaxity, Received:2015-12-25 Accepted:2016-05-10 orobstructionatanyportionofthenasaolacrimaldrainage system.Nasolacrimalductobstruction(NLDO)maybe Abstract congenitaloracquired.Manycasesevaluatedforepiphora arefoundtohaveacombinationofcauses.Insuchcases,a ·AIM:Toinvestigatetheetiology,diagnosis,management multiprongedtreatmentisnecessarytoaddressthepatients' andoutcomeofepiphorareferralstoanoculoplastic symptomsandassessmentoftreatmentresponsemaybe practice. neededtohelpconfirmtheworkingdiagnosis. · METHODS:Retrospectivechartreviewofpatients Dryeyeisamultifactorialinflammatorydiseaseaffectingthe referredforepiphoratoanoculoplasticclinicbetween ocularsurface.Arecentinvestigationshowedthatdryeye 2005and2009.Patient demographics,past history, comprisedasignificantproportionofpatients(40%)referred ophthalmicexamination,treatmentandoutcomewere fortearing [2].Tearingimprovedinmostcasesafterusing analyzed. topicallubricants.Thishighlightstheroleofdryeyeinthe · RESULTS:Therewere237subjectswithaprimary etiologyoftearinganddemonstratesthattearingisnota complaintofepiphora.Theyincluded130(55%)females simplesurgicalproblem.Compensatoryreflexhypersecretion and107(45%)maleswithanaverageageof55.9依25.9y. duetoevaporativelossisthoughttoberesponsiblefor Themostcommoncauseofepiphorawaslacrimal epiphora.Inourpractice,wefoundthatmanypatientswith obstruction (46%);followedbymultifactorialepiphora dryeyesymptomsreferredfortearingdidnothaveatear (22%),reflextearing(22%)andeyelidmalposition(11%). volumedeficiencybutasignificantnumberdidhavetear Differencesinprevalenceofetiologywerenotedinterms filminstability.AccordingtotheDryEyeWorkshopreport, ofageandgenderdistribution.Ofthe182(77%)patients tearfilminstabilityisoneofthecoreunderlyingmechanisms whoreturnedforfollowup,41(23%)reportedacomplete ofdryeye[3].Inapreviousstudy[4],wefoundthat206of1000 resolution and 102 (56%) reported a significant improvementintheirsymptoms. (20.6%)patientswithchronicepiphorahadmeibomitisand tearfilminstabilityasamaincauseoftearing.Medical ·CONCLUSION:Epiphoraisacommonconditionwith treatmentformeibomitisimprovedtearingsymptomsina manycauses.Athoroughhistoryandexaminationare majorityofthosepatients. requiredtoprovidetheappropriatetreatmenttailoredto Fewstudieshaveinvestigatedtheprevalenceofepiphoraby theunderlyingcause. etiology,andmanagementwithlong-termoutcome epiphora;etiology;lacrimaldisease;dryeye ·KEYWORDS: follow-upin anoculoplasticpractice.Theclinical DOI:10.18240/ijo.2016.12.08 characteristicsofepiphorareferrals,includingage distributionandgenderdifferencesare stillnotwell ShenGL,NgJD,MaXP.Etiology,diagnosis,managementand understood.Weperformedaretrospectivechartanalysisof outcomesofepiphorareferralstoanoculoplasticpractice. patientsevaluatedforepiphorawiththeaimofreportingthe 2016;9(12):1751-1755 clinicalcharacteristicsofpatientswithepiphoraand evaluatingtheirresponsetotreatment. 1751 Etiologyandmanagementofepiphora Table 1 Demographics and clinical characteristics of 237 patients x ± s ; n (%) Sex Laterality Etiology No. Age (a) Duration of epiphora (mo) Follow-up (mo) F M Unilateral Bilateral malposition 26 (11) 64.5±28.6 12 (46) 14 (54) 13 (50) 13 (50) 4.4±2.6 3.1±2.4 Reflex tearing 51 (22) 61.2±19.2 28 (55) 23 (45) 10 (20) 41 (80) 6.8±6.2 7.4±8.3 Lacrimal obstruction 108 (46) 45.2±28.1 70 (65) 38 (35) 81 (75) 27 (25) 17.9±18.5 9.5±13.0 Congenital NLDO 17 (7) 3.5±3.9 6 (35) 11 (65) 12 (71) 5 (29) 14.9±15.2 3.9±3.1 Upper obstruction 26 (11) 42.6±24.6 19 (73) 7 (27) 17 (63) 9 (37) 41.6±49.2 14.3±19.3 Lower obstruction 65 (27) 57.1±21.8 45 (69) 20 (31) 52 (80) 13 (20) 18.9±18.5 8.5±9.6 Multifactorial epiphora 52 (22) 69.0±14.1 20 (38) 32 (62) 16 (31) 36 (69) 21.2±19.4 3.7±3.0 2 causative factors 40 (77) 68.2±15.0 17 (43) 23 (57) 15 (38) 25 (62) 19.0±18.2 3.5±2.9 3 causative factors 12 (23) 71.5±10.3 3 (25) 9 (75) 1 (8) 11 (92) 24.3±21.8 4.4±3.6 Total 237 55.9±25.9 130 (55) 107 (45) 120 (51) 117 (49) 15.3±17.1 7.2±10.1

SUBJECTSANDMETHODS butwasconfirmedatfollow-upvisitsformanysubjects.For Subjects Weperformedaretrospectiveanalysisofpatients example,"eyelidmalposition"wasconfirmedasacauseof referredforepiphoratoouroculoplasticsclinicbetween epiphoraifsymptomsimprovedaftereyelidmalposition January2005andDecember2009.Additionaldatawere surgery; "reflextearing"wasconfirmedifsymptoms obtainedthrough2011toensureadequatefollowuptime. improvedafterdryeyetreatment;and"multifactorial" Subjectswere identifiedthroughanelectronicpatient epiphorawassuspectedifonlypartialimprovementof database,usingakeywordsearchfor"epiphora"or"tearing" tearingresultedaftereyelidsurgeryinapatientwherelid fortheirinitialclinicvisit.Informedconsentwasobtained malpositionwasthemainworkingdiagnosisandasecondary fromallsubjectsandthestudywasconductedinaccordance workingdiagnosiswasdeterminedafterinterventionor totheDeclarationofHelsinki. diagnosedinitiallybutnotdirectlytreatedbeforesurgery. Methods Demographics,medicalandocularhistorywere Dryeyetreatmentincludedwarmsoaks,lidscrubs,artificial collectedforallsubjects.Patientswerequestionedregarding tearsandflaxseedoilsupplementsfourtimesdaily.Patients thedurationandfrequencyoftearing,symptomsrelatedto diagnosedwithlacrimalobstructionunderwentsurgery dryeye(includingburning,itching,scratchinessandblurry includingballoondacryoplasty, vision),and symptomsrelatedtolacrimalobstruction (DCR),and conjunctivodacryocystorhinostomy(CDCR). (includingepiphora,dischargeandcrusting).Slit-lamp Patientswitheyelidmalpositionalsounderwentsurgical examinationfindingsincludedtearfilmappearance,lid correctionoftheunderlyinglidmalposition( margintelangiectasia,frothydischargeinthetearmeniscus, repair,medialspindleprocedureforpunctalectropion). poutingorpluggingofmeibomianorifices,expressionof StatisticalAnalysis Statisticalanalysiswasperformedusing meibomiansecretions,eyelidposition,,medial SPSS20.0(SPSSInc,Chicago,IL,USA).Descriptivestatistics canthalanatomy,punctalposition,and presenceof werepresentedasrawnumbersandpercentagefornominal .OthertestsincludedSchirmertest,tear variablesandasmean standarddeviationforcontinuous 依 break-uptime(TBUT),andirrigationtoassesslacrimal data.Differencesbetweengroupswereexaminedusing systempatency.Patientswithpreviouslacrimaloreyelid Pearson'sChi-squaredtestforcategoricalfactors.A surgery,facialnervepalsyorwhoalreadyreceivedtreatment value<0.05wasconsideredstatisticallysignificant. for symptom-relatedconditionspriortoreferralwere RESULTS excludedfromthestudy. DemographicsandDiagnoses Atotalof237subjectswith Weclassifiedthemostcommoncauseoftearingbasedon aprimarycomplaintofepiphorawereincluded.Themean pathophysiology.Categoriesincludedthefollowing:1) agewas55.9 25.9y(range1-93y),and55%( =130)were 依 eyelidmalposition( ,ectropionandeyelid female.Amongthem,49%( =117)ofcaseshadbilateral laxity);2)congenitalNLDO;3)acquiredupperlacrimal epiphora,and51%(=120)hadunilateralepiphora.The obstruction( punctalstenosis,canalicularobstruction);4) numberofpatientsaged60yearsorolderwas131, acquiredlowerlacrimalobstruction( dacryocystitis, accountingfor55%ofpatients.Demographicsandclinical NLDO);5)reflextearing ( dryeye,meibomitis, characteristicsofthepatientsarepresentedinTable1. );and6)multifactorialepiphora:morethanone Themostcommoncauseofepiphorawaslacrimal causativefactor( eyelidlaxityandpunctalstenosis). obstruction,occurringin108of237(46%)patients(27% Apreliminarydiagnosiswasmadeattheinitialevaluation occurredinthelowerlacrimalsystem,11%intheupper

1752 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 9熏晕燥援 12熏 Dec.18, 圆园16 www.ijo.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 lacrimalsystem,and7%wascongenitalNLDO),followed bymultifactorialepiphora( =52,22%),reflextearing( = 51,22%)andeyelidmalposition( =26,11%).Although unilateralepiphoraequallyprevalentasbilateralepiphorain allcasesoftearing(51%and49%,respectively),unilateral epiphorawasmorecommonincaseswith lacrimal obstructionthanothercauses,witharatioof3:1.Epiphora occurredbilaterallymoreoftenincaseswithreflextearing, witharatioof4:1( 2=53.51, =0.000). Subjects,excludingthosewithcongenitalNLDO,were dividedintothreegroupsbyagedistribution:<55y( =75), 55-75y( =75)and 75y(=69).Thereweresignificant 逸 differencesinetiologiesofepiphoraamongthethreeage groups( 2=23.88, =0.002;Figure1).Eyelidmalposition wassignificantlymorecommoninpatientsaged75yorolder Figure 1 Age distribution of the different etiologies of comparedwithyoungerpatients.Theproportionoflacrimal epiphora. obstructiondecreasedbyagewhilethatofmultifactorial epiphoraincreased.Thecasesofreflextearingdidnot significantlydifferindifferentagegroups. Incomparingthedifferentcausesofepiphorabygender, therewasasignificantdifferencebetweenfemalesandmales ( 2=17.98, =0.003;Figure2).Themostcommoncause of epiphorawaslowerobstructioninfemalesand multifactorialepiphorainmales. TreatmentandResponse Ofthe182(77%)patientswho returnedforfollowup,notreatmentwasnecessaryin6 patients,whereas52patientsrequiredtreatmentfordryeye, 23underwenteyelidsurgery,85hadlacrimaldrainage systemsurgery,10underwentbotheyelidandlacrimal drainagesurgery,4requiredacombinationofsurgeryand treatmentofdryeyeand2optedforobservationinlieuof surgery.Forty-onepatientshadcompleteresolutionof Figure2Genderdistributionsofthedifferentetiologiesof epiphora,102hadsignificantimprovement,24hadslight epiphora. improvement,12reportednochange,and3experienced worsesymptoms. whereasyoungerpatientspresentedmoreoftenwithpunctal Threesubjectsdevelopeddryeyeafterlacrimalsurgeryand stenosis,canaliculiobstructionorNLDO.Thisfindingis 1subjectreportedtearingduetotubeirritation.Incaseswith consistentwithpreviouslyreportedagedistributionoftearing Jonestubeplacement,3subjectsreportedthattubeswere accordingtoetiology [5-7],whichshowedarelativelyhigh lostand12reportedintermittenttubeobstructionasacause prevalenceofeyelidmalpositionintheelderlypopulation. fortearing. Eyelidabnormalitiesareoftenassociatedwithsignificant DISCUSSION ocularsurfacemorbidity( dryeye)[6-7].Thesefindingscan Epiphoraisacommonpresentingcomplaintforalmostevery partiallyexplaintheagedistributionofthedifferent ophthalmologistandespeciallyoculoplasticspecialists.There etiologiesofepiphorainourstudy,especiallywithmultiple is relativelylittleliteratureontheepidemiologyand etiologiesintheelderly. demographiccharacteristicsofepiphora.Thisstudypresents Causesofepiphorabetweenfemaleandmalewere newfindingsregardingpatientswithepiphora. significantlydifferentinourstudy-lacrimalobstructionwas Inourstudy,themeanageofpatientswas56yearsand morecommoninwomenthanmen.Consistentwithour abouthalfofpatientswereaged60yearsorolder,which findings,Viso [8] reportedthatwomenhadahigher indicatesthattheelderlypatientsweremoreinclinedtohave prevalenceofpunctalstenosisthanmenandsexwasan acomplaintofepiphora.Elderlypatientspresentedmore independentpredictor.Inanotherretrospectivestudyof2615 oftenwitheyelidmalpositionandmultifactorialepiphora, patientswithNLDO,femalesweremorefrequentlyaffected 1753 Etiologyandmanagementofepiphora thanmales,witharateof65.6%[5].Woog[9] alsoreportedthat Atfollowupevaluation,23%ofsubjectsreporteda femalescomprise73%ofpatientswithNLDO.Ithasbeen completeresolutionofand56%reportedasignificant postulatedthatthesmallerdiameter,longerlacrimalcanal improvementintheirsymptoms.Sibley [12] reporteda andinferiorbonylacrimalfossaleavefemales more 52%rateofsignificantsymptomimprovementorresolution vulnerabletochronicinflammation [10],whichmaycontribute overa2-yearperiod,highlightingthecomplicatedand tothisobservation. inconsistentetiologyofepiphora,suchasthe3cases Wefoundthat75%ofcaseswithlacrimalobstructionwere developingdryeyeafteroutflowsurgeryinourstudy. unilateral.Similartoourfinding,Francisco [11] reported Therefore,themanagementofepiphorashouldbeconsidered thatthemajorityoftheircasespresentedwithunilateral asamultifactorialissue. obstruction,witharatioof5:1,whereasreflextearingand Potentiallimitationsofourstudyincludeitsretrospective eyelidmalpositionoftenoccurbilaterally. design.Inaddition,dataofpatientswhodidnotfollow-up Theprevalenceoflacrimalobstructioninprevious werebasedonlyontheinitialassessment,whichmay clinic-basedsurveyswasreportedtorangefrom31.8%to potentiallyreflectaninaccuratediagnosisofthecauseof [2,12-14] 48.7% .Inoursample,lacrimalobstructioncomprised epiphorasincewouldcouldnotevaluatetheeffectofthe 46%ofthecasesanditwasthemostcommoncauseof recommendedtreatment. epiphora.Theprevalenceofdryeyevariesacrossdifferent Inconclusion,ourstudyreportstheetiology,diagnosis, [2] studies.MainvilleandJordan reportedasignificant managementandoutcomesofepiphorareferralstoan proportionofpatients(40%)referredfortearinghaddryeye. oculoplasticpractice.Themostcommoncauseofepiphora Sibley [12] reported29.2%ofpatientsreferredfordry waslacrimalobstruction;followedbymultifactorial eyehadepiphora.ACanadianstudyshowedthatdryeye epiphora,reflextearingandeyelidmalposition.Differences contributedto22%oftheallcasesofepiphora [13].Similarly, inetiologyprevalencearenotedwithrespecttoageand wefoundthattheproportionofdryeyeinthisstudywas genderdistribution. 22%.Thedifferencesinprevalencemayattributetothe ACKNOWLEDGEMENTS complexityofmultifactorialepiphora. ConflictsofInterest:ShenGL, None; NgJD, None; Ma Dryeyeisacommonocularsurfacedisorderwitha XP, None. complicatedetiology,whichcanbeclassifiedinto2major REFERENCES subtypes:aqueous-deficientsubtype(ADDE)resultingfrom 1BlackmoreKJ,AinsworthG,RobsonAK.Epiphora:anevidencebased adecreaseinlacrimalglandsecretionandevaporative approachtothe12minuteconsultation. 2010;35(3): subtype(EDE),inwhichthereisexcessiveevaporative 210-214. [15] waterloss .Tearfilminstability,togetherwithtear 2MainvilleN,JordanDR.Etiologyoftearing:aretrospectiveanalysisof hyperosmolarity,representthetwo coreunderlying referralstoatertiarycareoculoplasticspractice. mechanismsofdryeye [3].Teardynamicsaremaintainedbya 2011;27(3):155-157. complicatedarrangementoftearproductionbythelacrimal 3Thedefinitionandclassificationofdryeyedisease:reportofthe glands,distributionbyblinking,evaporationfromtheocular DefinitionandClassificationSubcommitteeoftheInternationalDryEye surfaceanddrainagethroughthenasolacrimalduct. Workshop. 2007;5(2):75-92. 4MaXP,NgJD.Chronicepiphorasecondarytoocularmeibomianitis. Disruptionofthebalanceofanyofthesefactorscanresultin 2014;14(3):386-389. tearfilminstability [16-17].Tearfilminstabilityleadstoan 5NemetAY,VinkerS.Associatedmorbidityofnasolacrimalduct increase inevaporativelossandthusstimulatesthe obstruction--alargecommunitybasedcase-controlstudy. neurosensoryreceptorsinthecorneaandconjunctiva.Reflex 2014;252(1):125-130. tearingsecondarytodryeyeisproducedbyneurosensory 6DamascenoRW,OsakiMH,DantasPE,BelfortRJr.Involutional stimulationofthelacrimalglandinanattempttoreducethe entropionandectropionofthelowereyelid:prevalenceandassociatedrisk tearfilmosmolarity.TheSchirmertestwithouttopical factorsintheelderlypopulation. 2011;27(5): anesthesiahasbeenusedtomeasurereflextearing.Ithas 317-320. beensuggestedthattheSchirmertestmaybeofdiagnostic 7AnsariZ,SinghR,AlabiadC,GalorA.Prevalence,riskfactors,and valuefordistinguishingADDEandEDEsubtypes [18].Inour morbidityofeyelidlaxityinaveteranpopulation. 2015;34(1): study,wefoundthatmanydryeyepatientswithepiphora 32-36. 8VisoE,Rodriguez-AresMT,GudeF.Prevalenceandassociationsof hadnormalSchirmertestvalues.Suchobservationshave externalpunctalstenosisinageneralpopulationinSpain. 2012;31 beennotedinpatientswithmeibomianglanddysfunction. (11):1240-1245. Theabnormalglandularlipidsmayleadtoincreased 9WoogJJ.Theincidenceofsymptomaticacquiredlacrimaloutflow evaporation,hyperosmolarityandinstabilityofthetearfilm, obstructionamongresidentsofOlmstedCounty,Minnesota,1976-2000(an increasedbacterialgrowthonthelidmargin,ocularsurface AmericanOphthalmologicalSocietythesis). inflammation,andevaporativedryeye[19]. 2007;105:649-666. 1754 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 9熏晕燥援 12熏 Dec.18, 圆园16 www.ijo.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 10GroesslSA,SiresBS,LemkeBN.Ananatomicalbasisforprimary 15BronAJ,TomlinsonA,FoulksGN,PeposeJS,BaudouinC,GeerlingG, acquirednasolacrimalductobstruction. 1997;115(1): NicholsKK,LempMA.Rethinkingdryeyedisease:aperspectiveon 71-74. clinicalimplications. 2014;12(2Suppl):S1-S31. 11FranciscoFC,CarvalhoAC,FranciscoVF,FranciscoMC,NetoGT. 16TsubotaK.Teardynamicsanddryeye. 1998;17(4): Evaluationof1000lacrimalductsbydacryocystography. 565-596. 2007;91(1):43-46. 17ZhangX,ChenQ,ChenW,CuiL,MaH,LuF.Teardynamicsand 12SibleyD,NorrisJH,MalhotraR.Managementandoutcomesofpatients cornealconfocalmicroscopyofsubjectswithmildself-reportedofficedry withepiphorareferredtoaspecialistophthalmicplasticunit. eye. 2011;118(5):902-907. 2013;41(3):231-238. 18LempMA,CrewsLA,BronAJ,FoulksGN,SullivanBD. 13WilliamsB,JohnsonD,HurstJ,KratkyV.Patternsandcausesof Distributionofaqueous-deficientandevaporativedryeyeina epiphorareferralstoatertiaryoculoplasticpractice. clinic-basedpatientcohort:aretrospectivestudy. 2012;31(5): 2014;49(2):180-182. 472-478. 14NemetAY.Theetiologyofepiphora:amultifactorialissue. 19NicholsKK.Theinternationalworkshoponmeibomianglanddysfunction: 2016;31(3):275-279. introduction. 2011;52(4):1917-1921.

1755